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May 28, 2025 Alison, McIntyre, Authorized Agent Cook County Public Health and Human Services 411 W 2nd St. Grand Marais, MN 55604 License Number: 810854 CORRECTION ORDER Dear Alison: On March 28, 2025, a Department of Human Services (DHS) licensor conducted a licensing review at your facility, Cook County Wilderness Outpatient Treatment Program located at 411 W 2nd St., Grand Marais, MN 55604. This review was conducted to determine compliance with state and federal laws and rules governing the provision of Substance Use Disorder under Minnesota statute, chapter 245G. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Policies, Practices, and Procedures 1. Violation: The license holder did not monitor the implementation of policies and procedures necessary to maintain compliance with licensing requirements. The policy and procedure manual did not contain the following: a. Assessment and treatment planning policies that were consistent with current statute requirements; b. Policies and procedures consistent with current commissioner approved tuberculosis education; and c. Policies and procedures consistent with current HIV minimum standards; d. Clients were oriented to an outdated version of the grievance procedure that did not include the correct telephone number and address of the Board of Behavioral Health and Therapy. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 14, paragraph (b), 245A.19, and 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that provider policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit the revised policies and procedures identified above that meet all applicable requirements. 2. Violation: The license holder’s service initiation policy did not include the titles of all staff members authorized to initiate services for clients. Statute Violated: Minnesota Statutes, section 245G.14, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation policy meets all applicable requirements. Within 30 days of receipt of this order, the license holder must submit a service initiation policy that meets all applicable requirements. 3. Violation: The license holder’s grievance procedure did not meet requirements. The grievance procedure did not require that the license holder will respond to the client’s grievance within three days of a staff members receipt of the grievance. Statute Violated: Minnesota Statutes, section 245G.15, subdivision 2. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that service initiation policy meets all applicable requirements. Within 30 days of receipt of this order, the license holder must submit a grievance procedure that meet all applicable requirements. 4. Violation: The license holder’s telehealth policy and procedures did not meet requirements. The telehealth policies and procedures did not include the following: a. The categories or types of services provided through telehealth; and b. Established protocols addressing how and when to discontinue telehealth services. Statute Violated: Minnesota Statutes, section 245G.07, subdivision 4, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that telehealth policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit a telehealth policy that meets all applicable requirements. 5. Violation: The license holder’s treatment services description did not meet requirements. The treatment services description did not contain: a. A description of treatment services, including the amount and type of services provided; b. Identification of which services meet the definition of group counseling; and c. The program’s treatment week. Statute Violated: Minnesota Statutes, section 245G.12. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment services and description meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment service description that meets all applicable requirements. 6. Violation: The license holder’s client attendance policy and procedure did not identify how the program will track the date, duration, and nature of each treatment service provided to the client. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that client attendance policy and procedures meet all applicable requirements. Within 30 days of receipt of this order, submit an attendance policy that meets all applicable requirements. 7. Violation: The license holder’s program abuse prevention plan did not include an assessment and evaluation of the gender of the persons served relevant to minimizing risk of abuse for clients. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that program abuse prevention plan meets all applicable requirements. Within 30 days of receipt of this order, submit a program abuse prevention plan that meets all applicable requirements. 8. Violation: The license holder’s maltreatment of vulnerable adults’ policy did not meet requirements. The policy did not include that the internal review must be completed within 30 calendar days. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (b). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that maltreatment of vulnerable adults’ policy meets all applicable requirements. Within 30 days of receipt of this order, submit a maltreatment of vulnerable adults’ policy that meets all applicable requirements. 9. Violation: The license holder’s personnel policies and procedures did not meet requirements in the following ways. The personnel policies did not contain the following: a. Job descriptions specifying qualification requirements for treatment director and alcohol and drug counselor supervisor; b. Job performance evaluations based on standards of job performance conducted on a regular and continuing basis, including a written annual review; c. A description of behavior that constitutes grounds for disciplinary action, suspension, or dismissal for policies prohibiting: 1) Personal involvement with a client in violation of Minnesota Statutes, chapter 604; and 2) Client abuse described in Minnesota Statutes, sections 245A.65, 260E, 626.557, and 626.5572; d. A written plan for orientation within 24 working hours to: 1) Client confidentiality; 2) HIV minimum standards; and 3) Client needs; e. Response to a staff member with a behavior problem that interferes with the provision of treatment services; and f. Policy prohibiting license holders, employees, subcontractors, and volunteers from abusing prescription medication. Statute Violated: Minnesota Statutes, sections 245A.04, subdivision 1, paragraph (c), and 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that personnel policies meet all applicable requirements. Within 30 days of receipt of this order, submit a personnel policy that meets all applicable requirements. 10. Violation: The license holder’s transfer of clients and records upon closure procedure did not meet requirements. There was not a signed agreement or other documentation indicating that a county or similarly license provider would provide follow up services as necessary. Statute Violated: Minnesota statutes, section 245A.04, subdivision 15a, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that transfer of clients and records meets all applicable requirements. Within 30 days of receipt of this order, submit a signed agreement that demonstrates compliance. Personnel Files 11. Violation: One personnel file was reviewed for requirements governing personnel file contents (personnel file numbered 1) and did not meet requirements. The personnel file did not contain a written annual review for calendar year 2024. Statute Violated: Minnesota Statutes, section 245G.13, subdivision 1. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that job performance evaluations meet all applicable requirements. Client Files 12. Violation: One of three client files reviewed for requirements governing initial services plan (ISP) (client file numbered 2) was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 1, and 245G.09, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that initial services plans meet all applicable requirements. 13. Violation: One of three client files reviewed for requirements governing vulnerable adult determination (client file numbered 2) was not completed within 24 hours of the day of service initiation. Statute Violated: Minnesota Statutes, sections 245G.04, subdivision 2, paragraph (a). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that vulnerable adult determination meets all applicable requirements. 14. Violation: Three of three client files reviewed for requirements governing comprehensive assessments (CA) did not meet requirements in the following ways: a. There was no documentation that the CA was reviewed and updated as clinically necessary by the end of the fifth day on which a treatment service was provided (client file numbered 1); and b. The comprehensive assessment did not include the following information: 1) The client’s housing status and household members (client file numbered 3); 2) The status of the client’s basic needs (client files numbered 2 and 3); 3) Important developmental incidents in the client’s file (client files numbered 2 and 3); 4) The client’s family health history (client file numbered 2 and 3); and 5) A recommendation for the ASAM level of care identified in Minnesota Statutes, section 254B.19, subdivision 1 (client files numbered 2 and 3). Statute Violated: Minnesota Statutes, section 245G.05, subdivisions 1 and 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that comprehensive assessments meet all applicable requirements. Within 30 days of receipt of this order, submit a comprehensive assessment that demonstrates compliance. 15. Violation: Three of three client files reviewed for requirements governing individual treatment plans (ITP) did not meet requirements. There was no documentation of the following: a. The qualified staff member’s dated signature (client file numbered 2); b. The ITP contents did not include the following: 1) A treatment strategy (client files numbered 1 and 3); 2) The ASAM level of care under which the client is receiving services (client files numbered 1 and 3); and 3) Maintenance strategy goals and methods to address relapse prevention and to strengthen the client’s protective factors (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 1 and 1a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plans meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan that meets all applicable requirements. 16. Violation: Three of three client files reviewed for requirements governing treatment service documentation did not meet requirements. There was no documentation of the client’s response to each treatment service for the following dates: a. November 14, 2024, December 17, 2024, December 19, 2024, January 14, 2025, and January 16, 2025 (client file numbered 1); b. October 24, 2024, and October 29, 2024 (client file numbered 3); and c. March 18, 2025 (client file numbered 3). Statute Violated: Minnesota Statutes, section 245G.06, subdivision 2a. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that treatment service documentation meets all applicable requirements. Within 30 days of receipt of this order, submit treatment service documentation that meets all applicable requirements. 17. Violation: One of two client files reviewed for requirements governing treatment plan reviews (TPR) (client file numbered 1) did not meet requirements in the following ways: a. The TPR did not indicate the span of time covered by the reviews dated November 11, 2024, November 25, 2024, December 23, 2024, January 20, 2025, and February 17, 2025; and b. There was no documentation of the participation of others involved in the individual’s treatment planning, including when services are offered to the client’s family or significant others. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 3. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that individual treatment plan reviews meet all applicable requirements. Within 30 days of receipt of this order, submit a treatment plan review that meets all applicable requirements. 18. Violation: Three of three client files reviewed for requirements governing record keeping (client files numbered 1, 2, and 3) did not meet requirements. The Gain-SS assessment was not signed and dated by the staff member making the entry. Statute Violated: Minnesota Statutes, section 245G.09, subdivision 1, paragraph (c). Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure that record keeping meets all applicable requirements. 19. Violation: One of two client files reviewed for requirements governing discharge summaries (client file numbered 2) did not meet requirements. There was no documentation of the following: a. The client’s living arrangements at service termination; and b. Service termination diagnosis. Statute Violated: Minnesota Statutes, section 245G.06, subdivision 4. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure discharge summaries meet all applicable requirements. Written Response Required If you fail to correct the violation(s) specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of the corrective action ordered must be sent to your licensor by email at Charlene.m.hanson@state.mn.us or by mail: Commissioner, Department of Human Services ATTN: Char Hanson Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General, Legal Counsel’s Office - Licensing 444 Lafayette Road North St. Paul, MN 55155 Legal authority This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6617 or at Charlene.m.hanson@state.mn.us. Sincerely, Char Hanson, Licensor Licensing Division Office of Inspector General
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